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Summary Cognitive Behavior Therapy, ISBN: 9781462544196
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Summary of the whole book. With colours and frames. Also summary of chapter 5 and 10 of Page & Strizke.
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Short summary of Beck's 'Cognitive Behavioral Therapy' book for the CBT course
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Stritzke Chapter 5: Case FormulationTreatment = locomotive, client’s problems = carriages, case formulation = the coupling that holds
the two together
Functional analysis: Identify and understand the function of behavior, so why people do something.
Functional relationship between environmental factors and the problematic behavior.
GOAL: identification of manipulative, causal variables. Bv. There’s nothing to change about
childhood abuse anymore, so this is not a good target variable.
Chief elements of functional analysis:
Antecedents
o Variables that are proximal in time and distal to behavior.
o Aangeven verschil tussen variabelen belangrijk in origin of the problem
en variabelen die probleem in stand houden, maintenance of the problem
o Verschil tussen moderator (directe effect on behavior)en mediator (influence
relation between behavior and variable)
Behavior
o Frequentie, duratie, intensiteit, topography (typical and unusual patterns)
Consequences
Assessment of behavior via 3 methodes:
Indirect assessment: Questioning observer about occurrence and non-occurrence of
behavior
Analogue assessment: artificial conditions are constructed to test hypothesis about the
hypothesized reinforcers.
Naturalistic assessment: observing behavior
Cognitive behavioral Case Formulation (Persons and Tompkins, 2007)
Problem list (behavior in ABC)
Assign a DSM diagnosis
Select a nomothetic formulation of the anchoring diagnosis
= an explanation of the type typically found In the literature that serves
to provide an account of all people who have a diagnosis.
o Includes diagnostic description, giving causal explanation of why symptoms
occur and how they are related
o Use theoretical models
Individualize the template
o Collect additional information concerning cognitive, behavioral, emotional, and
somatic aspects of the problem
, o Examine the relationship between variables
Propose hypotheses about the origins of the mechanisms
o How client has developed cognitive schemata that underlie the problems
o How the dysfunctional behaviors were learned
o How functional behaviors were not acquired
o How emotional regulation deficits were acquired
o Origins of any genetic of biological vulnerability
Describe precipitants of the current episode or symptom exacerbation
- Precipitants:
o events or stimuli that case the particular problem in a particular context.
o Analogues to activating events in Functional Analysis.
- Activating events: explain the problem more generally and explain consistency across
situations
Strengths Person’s and Tompkins (2007) approach:
o Process of diagnostic assignment is assigned a key role
o Nomothetic formulations are linked explicitly with idiographic accounts
Weaknesses:
o Fails to describe how the hypotheses are linked to particular treatments or
treatment plans
o There is no encouragement to identify potential obstacles to treatment
Proposition for a case formulation according to Page & Strizke (2005)
Presenting problems
Predisposing factors
o Any experiences, social, familial or cultural issues, and temperamental factors that
may set the stage for the emergence of the problem or that may influence the
manifestation of the problem
Precipitating variables
Perpetuating cognitions and consequences
Provisional conceptualization
o Looks backwards to explain origins of problem
o Looks around to understand current problem
o Looks forward to make a prognosis
Prescribed interventions
Potential problems to treatment and client strengths
“Even when applying an existing model to a client, it is important to test the validity of the
formulation. This can be done by presenting the formulation to the client in a formal manner and
asking for feedback as to its ability to consolidate the client’s problems. Or test it with psychometric
tests.”
,See Page 77 of article for an example of a filled in case conceptualization according to the article.
Case formulations in Interpersonal Psychotherapy
IPT is structured in three phases:
1. Assessment (interpersonal case formulation) & therapeutic contract.
2. Work on nominated problemated areas
3. Termination
First phase
- Review symptoms systematically
o Survey but also ask patient !
- Confirmation diagnosis
- Explain nature of depression
- Identify ways it can be treated
- Encourage patient to adopt a sick role
o Sick role: patient is exempt from certain normal social obligations and certain types of
normal responsibilities, considered to be in a state as socially undesirable, to be gotten out of
as quickly as possible.
- Assessment value of medication
IPT framework consists of 4 problem ares:
Loss and growth
o Grief reactions
o Role transitions
Interpersonal Communication
o Interpersonal role disputed (people in a relationship have unshared or unmet
expectations)
o Interpersonal deficits
A role transition often leads to grief reactions, because of grief of the role one had before the role
transition.
Summary and contrast with CBT
Emphasis and treatment plan is different in IPT than CBT.
In IPT; no predisposing factors
Important difference: Consideration of Perpetuating cognitions and consequences
o Important factor in depression
o Beliefs, expectations are not met
o Beliefs and expectations are not modified
o Lack of positive reinforcement and lot of punishment
o Intervention in CBT would be: behavioral activation and cognitive therapy.
,Chapter 1: Introduction to Cognitive Behavior Therapy
In all forms of CBT:
- Treatment based on cognitive formulation
o Maladaptive beliefs
o Behavioral strategies
o Maintaining factors that characterize a specific disorder
- Treatment based on conceptualization of individual clients
o Underlying beliefs
o Patterns of behavior (avoidance)
The CBT theoretical model
Cognitive model
o Dysfunctional thinking influences mood and behavior
o Evaluation of thinking
Automatic thoughts
Examine validity of thought
Cognitions at three levels:
o Automatic thoughts
o Intermediate thoughts (underlying assumptions; “If….then”)
o Core beliefs
Modification of thoughts and beliefs
CBT and Recovery-Oriented Cognitive Therapy
CT-R maintains cognitive model in conceptualizing individuals and planning and delivering treatment.
Adds emphasize on adaptive beliefs and behavioral strategies, and factors that maintain a
positive mood.
Time orientation is different:
o CBT: problems that arose in past week
o CT-R: focus on client’s aspirations for the future, their values
“Rather than emphasizing symptoms and psychopathology, CT-R emphasizes strengths, personal
qualities, skills and recourses.”
,Chapter 10 Strizke: Confidentiality
Responsibility of explaining confidentiality and its exceptions
Exceptions:
1. When patient intends to harm himself or others
2. Abuse or severe neglect of children or elderly
3. Subpoena from judge or court
When working with children: Balance patient’s need for confidentiality with parent’s need for
information.
Guidelines:
Weigh pros and cons
Discuss with parents importance of child’s need for privacy and to help with treatment
Explain parents the importance of therapist being able to make professional decisions about
what is necessary for parents to know. In accordance with professional ethics and applicable laws.
Reassure parents. They will be informed of any risk when they can help to manage.
Limit discussions with teachers and principals to
o Information necessary for child’s safety
o General information about prognosis
o Assurances that the school’s concerns are being addressed in child’s behavior
o Things school personnel can do to assist the child’s treatment
Discuss with child the nature and extent of arrangements planned for the exchange of
information with others.
Controlling the Scope of Disclosure
If information has to be shared with third parties, type and context of disclosure should be carefully
controlled.
Different consent forms that correspond to different types and levels of disclosure:
Requesting information from others; one way flow
Releasing information to others; one way flow
Exchanging information with others; two way flow
When disclosing information to third parties, better to give too little information than too much.
Always seek consent from patient before disclosing any patient information.
Securing patient information
All patient records should be stored securely and locked.
Some guidelines:
Return records
Do not leave any materials on which identifying patient information is visible
Ensure that computers and networks have appropriate security; especially nowadays.
etc. Complete list on page 162
,Chapter 2: Overview of Treatment
Principles of treatment:
1. CBT treatment plans are based on an ever-evolving cognitive conceptualization
a. Key cognitions, behavioral strategies and maintaining factors, but also strength,
positive qualities, and recourses.
Conceptualize difficulties in three time frames
o Current cognitions that are obstacles to aspiration
Behavior obstacles that maintain problem
o Identify precipitating factors that influence clt’s perception at onset of mental illness
o Hypothesize about the key developmental events and clt’s enduring patterns of
interpreting these kinds of events that may have predisposed clt to mental illness.
2. CBT requires a sound therapeutic relationship
a. Asking reaction to treatment plan, making collaborative decisions about treatment,
providing rationales for interventions, using self-disclosure, eliciting feedback during
and at end of sessions, working hard to achieve progress.
3. CBT continually monitors clients progress
4. CBT is culturally adapted and tailors treatment to the individual
5. CBT emphasizes the positive
6. CBT stress collaboration and active participation
a. After some sessions, encourage clt to become increasingly active in the session.
7. CBT is aspirational, value based, and goal oriented
a. In initial session, ask clt about:
i. Values
ii. Aspirations
iii. Specific goals for treatment
8. CBT initially emphasizes the present
a. You only shift focus to the past in three circumstances:
i. When the client expresses a strong desire to do so
ii. When work directed toward current problems and future aspirations
produces insufficient change
iii. When you judge that it’s important for you and clients tu understand how
and why their key dysfunctional ideas and behavioral coping strategies
originated and became maintained.
9. CBT is educative
a. A major goal of treatment is to make the process of therapy understandable.
i. Educate about nature and course of clts disorder
ii. Educate about process of CBT
iii. Structure of sessions
iv. Cognitive model
v. Future sessions: additional psychoeducation, presenting ongoing and refined
conceptualization
vi. Throughout treatment: teach client to use techniques themselves.
10. CBT is time sensitive
11. CBT sessions are structured
a. Work via standard format
, i. First part sessions: reestablish therapeutic alliance, review the Action Plan,
collect data so you and client can collaboratively set and prioritize the
agenda.
ii. Second part of the session: You and client discuss issues or goals on agenda.
This naturally leads to Action Plan
iii. Final part of session: You or client summarizes session. Make sure Action
Plan is reasonable and elicit and respond to client’s feedback.
12. CBT uses guided discovery and teaches clients to respond to their dysfunctional cognitions
a. Ask client questions to help identify their dysfunctional thinking, evaluate the validity
and utility of their thoughts, and devise a plan of action.
i. Socratic questioning, to let client see you’re truly interested in collaborative
empiricism (helping determining accuracy and utility of ideas)
ii. Ask about meaning of thoughts to uncover underlying beliefs he holds about
client self, his world, and other people.
iii. Teach client to credit himself
13. CBT includes Action Plans (therapy homework)
a. Action Plans consist of:
i. Identifying and evaluating automatic thoughts that are obstacles to clients’
goals
ii. Implementing solutions to problems and obstacles that could arise in the
coming week and, or
iii. Practicing behavioral skills learned in session
iv. Rule of thumb: anything we want clients to remember is recorderd.
14. CBT uses a variety of techniques to change thinking, mood, and behavior.
,Chapter 4 The therapeutic Relationship
Four essential guidelines
- Treat every client at every session the way I’d like to be treated if I were a client
- Be a nice human in the room and help the client feel safe.
- Remember, clients are supposed to pose challenges; that’s why they’re here.
- Keep expectations for my client and myself reasonable
Demonstrating good councelling skills
Maak gebruik van Rogerian counceling skills: empathy, genuineness, positive regard.
Important basic counseling skills:
Empathy
Acceptance of client
Validation
Accurate understanding
Inspiring hope
Genuine warmth
Interest
Positive regard (… was such a good thing to do!)
Caring
Encouragement
Positive reinforcement (how great that you finally got your taxes done!)
Offering a positive view of the client
Compassion
Humor
Monitoring client’s affect and eliciting feedback
Negative thoughts about clients need to be positively reinforced. Always pay attention toe motions
and body language. With negative feedback always tell client it’s good they told you this.
Ask regularly for feedback.
Collaborating with clients
Collaboration is a hallmark of CBT.
Make decisions together such as:
Which goals to work toward during a session
How much time to spend on various goals and obstacles
Which automatic thoughts, emotions, behaviors, or physiological responses to target
Which interventions to try
Which self-help activities to do at home
How often to meet
When to start tapering sessions and ending treatment
,Tailoring the therapeutic relationship to the individual
Individually assess and adjust the degree to which you use counseling skills with each client to build
therapeutic relationship. Not everyone is the same. Some clients view warmth and empathy as
suspicious, patronizing of uncomfortable. Take into account: age, gender, socoeconomic status,
culture, etc.
Using self-disclosure
Purpose of self-disclosure:
- Strengthening therapeutic relationship
- Normalizing client’s difficulties
- Demonstrating how CBT can help
- Modeling a skill
- Serving as a role model
Ook hier inschatten wanneer wat te zeggen. Bv: uitdrukken van genuine sadness only after a trusting
relationship has formed.
Repairing ruptures
When getting negative feedback:
First; provide positive reinforcement
Then conceptualize the problem and plan a strategy
First wonder whether client is right. If yes, apologize genuinely and then offer another
solution.
If you made no mistake:
Express empathy
Ask for additional information in the context of the cognitive model
Seek agreement to test the validity of the thought.
Helping clients generalize to other relationships
If client has incorrect negative feedback, you can generalize it to other people in their surrounding.
Managing negative reactions towards clients
It’s important to have an accurate cognitive conceptualization your own believes and behavior and
their reciprocal interactions.
If you have a client you do not want to see, use CBT techniques on yourself. P.69
, Chapter 5 Beck: The evaluation session (assessment)
Evaluation session = first session, before 1st BA. Takes 1-2 hours, sometimes longer.
Objectives of assessment:
- Collect information, both positive and negative to make an accurate diagnosis and create an
initial cognitive conceptualization and treatment plan
- Determine whether you will be an appropriate therapist and can provide the appropriate
“dose” of therapy (level of care, frequency of sessions, and duration of treatment).
- Figure out whether adjunctive services or treatment (such as medication) may be indicated
- Initiate therapeutic alliance with the client
- Educate the client about CBT
- Set up an Action Plan
STRUCTURE OF EVALUATION SESSION:
Greet client
Collaboratively decide whether family member or friend should participate
Set the agenda and convey appropriate expectations for the session
Conduct the Psychosocial assessment
Get broad goals
Relate your tentative diagnosis and your broad treatment plan and
educate client about CBT
Collaboratively set an Action Plan
Set expectations for treatment
Summarize the session and elicit feedback
PART 1: Setting the agenda = tell client what to expect
PART 2: CONDUCTING THE ASSESSMENT
Areas of assessment (a lot):
Eliciting description of a typical day
Additional insight into daily experiences, facilitates goal setting, helps pinpoint positive activities that
you can encourage.
Take notes and look for:
Variations in their mood
Degree to which they are interacting with family, friends,
people at work
General level of functioning at home, work, and elsewhere
How they’re spending their free time
Activities that bring them a sense of pleasure, accomplishment,
and/or connection
Self-care activities
Activities they’re avoiding
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